Do not resuscitate, but only anaesthetise!

The intersection of anaesthesia and Do-Not-Resuscitate (DNR) orders presents a complex ethical and medical dilemma. A DNR order is a directive by a patient or their proxy to forgo resuscitative efforts, such as cardiopulmonary resuscitation (CPR) or advanced cardiac life support, in the event of cardiac or respiratory arrest. Anaesthesia, used in various medical and surgical procedures, inherently carries risks of reversible complications that may mimic scenarios requiring resuscitation. This raises an essential question: Should DNR orders be automatically paused or modified during procedures involving anaesthesia? Exploring the ethical, clinical and practical dimensions of this issue reveals why this consideration is critical for patient-centred care.

DNR was first described as recent as the 1970s at Mass General Hospital, Boston, after which it was soon adopted internationally.[1] It is based on many factors: the realistic outcome expectations of the well-informed patient, assumed futility of life-saving measures in the case of a cardiopulmonary arrest, an irreversible path towards death or poor quality of life due to the disease process, or the patient’s choice to ‘die naturally’. When patients or their decision-makers opt for DNR, the understanding is that resuscitation is highly unlikely to result in a good outcome. The option of a DNR order is a step forward in giving the patient the autonomy to choose the end goals of their health care instead of being at the mercy of a system that attempts to save and prolong life at whatever cost. Historically, this issue was discussed in great detail by Truog.[2] He emphasised the need for guidelines for managing patients with numerous causes of perioperative complications. Over the years, the practice has been to discuss various scenarios with the patients and their decision-makers that are otherwise not properly understood.

If a DNR order strictly prohibits resuscitation, medical teams may be placed in an ethical bind, potentially compromising the safety of the procedure. By definition, many anaesthetic manoeuvres might be categorised as ‘resuscitation’. The patient also needs close monitoring by an anaesthesiologist, as anaesthetic agents, anaesthetic procedures and surgical events can result in a cardiac arrest. In many instances, this witnessed arrest can be reversed with prompt intervention, which results in a much better outcome than non-operating room arrests.[3] This is a unique characteristic of the operating room, where there are multiple healthcare providers, anaesthesiologists, surgeons and nurses, all working as a team on one patient perioperatively. The context of a witnessed intraoperative arrest is different from a cardiac arrest outside the operating room, where both the aetiology and the response time are different.[4] An intraoperative arrest has a much higher likelihood to be an iatrogenic cause – surgical or anaesthetic – and, therefore, should be viewed differently as it is more likely to be reversible.[2] Although there is no guarantee that a perioperative arrest will have a good outcome, it may be presumed that a patient who chooses to have surgery will want to survive beyond it.

Many publications have criticised this approach, claiming that it may diverge from the patient’s true long-term goals.[5] Patients are presumably not as concerned about what caused the arrest and its reversibility as they are about the after-effects: rib fractures from chest compression, prolonged intensive care unit (ICU) stay and painful ICU procedures are some of these.[6] Forcing them down this road may be considered a removal of their autonomy. At the same time, denying a patient a palliative procedure, or one that prolongs life and improves comfort, on the grounds of their DNR status is not ethical either.[7] An automatic suspension of DNR is often not clearly communicated to patients who do not understand why or for how long. There is also the fact that ‘resuscitation’ itself can be understood in many ways: vasopressors, intubation, mechanical ventilation, central lines, chest compressions and defibrillation.[8] A synchronised electrical shock (cardioversion) can normalise an unstable rhythm, but this may be confused with defibrillation for cardiac arrest. Patients may be agreeable to some interventions but not others. This can further complicate the situation as anaesthesia cannot be provided without some of these.

Guidelines around perioperative DNR have evolved, taking these factors into account. The American Society of Anesthesiologists recommends a preoperative discussion with the patient or surrogate and reconsideration of the DNR status into one of three categories.[9] ‘Full attempt at resuscitation’ would mean that all limitations are suspended perioperatively; this is usually extended to the immediate postoperative period. ‘Limited attempt with regard to specific procedures’ states that some procedures are acceptable (e.g. electrical cardioversion), while others are not (e.g. chest compressions). Those procedures that were vital to the surgery and those that were optional should be explained to the patient before making this decision. ‘Limited attempt with regards to patient’s goals and values’ presents a seemingly more ideal scenario where patients communicate their expectations (e.g. do not want to have multiple invasive lines, neurological compromise or a feeding tube), and the provider decides what resuscitation measures are accordingly appropriate; for example, a hypovolaemic arrest due to acute haemorrhage may be resuscitated with additional venous access and blood transfusions, whereas a massive myocardial infarction might not.[10] However, real-time decisions can be more challenging to make, as the scenario may not be as clear-cut and it is not easy to decide not to resuscitate based on the presumed understanding of goals and values during the high-stress moments of an intraoperative arrest. Ideally, an individualised plan should also be made about when to reinstate the original DNR order both intraoperatively and postoperatively.[11] This exercise is likely to be very difficult and would involve different surgical procedures, anaesthesia techniques and complications. Palliative procedures like surgery for colostomy to relieve large bowel obstruction due to malignancy could be one such scenario. If such a patient with DNR orders has an unprecedentedly difficult airway and has a hypoxic arrest just as the emergency surgical airway is secured, what would the anaesthesiologist do? Similarly, if the patient develops intraoperative arrhythmias due to hyperkalaemia and arrests, would the anaesthesiologist be justified to sit back and let the documented DNR order be followed? Would this truly be in line with the patient’s wishes?

The Association of Anaesthetists of Great Britain and Ireland also recommends a preoperative discussion with the patient or surrogate. However, it suggests that it is usually appropriate to suspend DNR perioperatively entirely.[12] From these multiple points of view, we can infer that there is no ‘one-size-fits-all’ policy. Patients should be educated about the different scenarios and outcomes of a perioperative arrest, and their autonomy in decision-making should be supported to allow for perioperative reconsideration of DNR orders.

Another aspect to consider is the psychological effect of perioperative DNR on healthcare providers, especially when there is a clearly reversible cause of arrest, but one must withhold life-saving skills and simply watch the patient die. When an anaesthesiologist puts a patient under anaesthesia, they assume full responsibility for the patient’s life for the duration of that anaesthetic as well as postoperatively; the surgeon also has a similar bond with the patient during and after surgery. A perioperative death is traumatic for all involved. There can be added guilt and long-term effects if this reversible cause of cardiac arrest is iatrogenic. The question arises as to the impact of forcing medical professionals to work with their hands tied; there may be a tendency towards a more cautious anaesthetic with lower doses or a more conservative surgical plan, both leading to suboptimal outcomes for the patient. If death on the table occurs in the presence of a DNR order, it must be treated as an ‘expected death’ and not ‘unexpected’; further in-depth evaluation and root cause analysis may not be required.[13]

The best and most logical intervention is educating the patient and surrogate decision-makers and sharing decision-making with the treating team about reassessing the DNR status perioperatively.[5,14,15] However, this is likely to be difficult and time-consuming and would have to be individualised for various surgical procedures or anaesthesia techniques.

THE INDIAN SCENARIO

In 2018, the Indian Supreme Court ruled that the ability to refuse life-sustaining treatment is a fundamental right to liberty and dignity.[16] Health care in India is growing and advancing rapidly, serving Indian citizens and now increasingly foreigners as well through medical tourism. Some foreigners may have pre-existing DNR orders from their country of origin. In 2020, the Indian Council of Medical Research published a consensus on ‘Do Not Attempt Resuscitation’,[17] which has served useful guidelines tailored to the multicultural Indian context. As this practice becomes prevalent throughout the country, it is important to interpret this in the setting of anaesthesia and perioperative care.

This concept of DNR orders is not widely understood by the Indian public or even by many healthcare providers. While DNR orders are legally permissible, their implementation varies across hospitals. The legal process for creating and enforcing advance directives, including DNR orders, is cumbersome. Some private hospitals, particularly those in urban areas, may be more familiar with DNR protocols and advanced care planning. However, public hospitals often lack the infrastructure or policies to support such directives. Another important issue is regarding the cultural and religious beliefs that emphasise the sanctity of life. Indian healthcare settings often focus on aggressive treatment and prolonging life, even in terminal cases. Discussions about withholding or withdrawing treatment are not common. In a society where life is often considered sacred, the idea of withholding life-saving measures can face resistance from families, healthcare providers and religious groups. Most recently, Indian guidelines for CPR have been developed and are being implemented nationwide.[18] In the same vein, nationwide guidelines need to be made in India for perioperative DNR to give healthcare providers clarity in decision-making. The Indian legal system needs to be aware of the complexities and grey areas of these decisions, and it should provide room for immunity to healthcare providers if the outcome is undesirable in retrospect. In all these, patient autonomy should ultimately and always be respected.

In conclusion, we believe that despite ambiguity regarding the best approach, in the Indian context, the easiest and most non-controversial method would be to suspend DNR orders during the perioperative period. The duration of this perioperative period can be discussed with the patient or their decision-makers and planned by the treating team. DNR orders are typically created in the context of chronic or terminal illnesses where aggressive resuscitation may only prolong suffering. However, complications during anaesthesia are often unrelated to the patient’s underlying condition and are usually reversible. Automatically reversing the DNR order ensures that the patient’s death does not occur prematurely due to an avoidable complication rather than the natural progression of their illness. Lastly, except for emergencies, healthcare providers who feel conflicted in any way about providing anaesthesia with a DNR in place should have the option to withdraw from the care of that patient and facilitate another provider in their place without compromising patient care.